Healthcare Provider Details

I. General information

NPI: 1518919802
Provider Name (Legal Business Name): MANUEL B DESAGUN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3102 EAST HIGHWAY AVE
PATTON CA
92369
US

IV. Provider business mailing address

1600 9TH STREET ROOM 205 MAILSTOP 2 3
SACRAMENTO CA
95814-6414
US

V. Phone/Fax

Practice location:
  • Phone: 909-425-7000
  • Fax: 909-425-7520
Mailing address:
  • Phone: 916-654-2431
  • Fax: 916-654-3186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA63216
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: